What Are Surprise Bills: Understanding the No Surprises Act

Imagine going to the emergency room, making sure you are at an in-network hospital and showing your insurance card, only to get hit with a massive, unexpected bill weeks later. Sound familiar? That’s called a surprise bill, and it used to happen all the time. Surprise medical bills can amount to thousands or even tens of thousands of dollars, pushing families into debt or bankruptcy. They undermine trust in the health system since patients believe they have in‑network coverage but face enormous bills. Studies show that approximately 1 in 5 emergency department visits resulted in a surprise bill before recent reforms KFF. However, since the implementation of the No Surprises Act on January 1, 2022, you are protected from these unexpected bills.

What Is a Surprise Medical Bill?

A surprise medical bill is an unexpected bill for services by a provider or facility that is out-of-network, with which your insurer does not have a negotiated rate. These bills arise because out‑of‑network providers can “balance‑bill” you for the difference between what your insurer pays and their full charge. Patients often discover these bills weeks or months after care, when the provider files for payment.

Common Scenarios:

• Emergency Care: In true emergencies, you have little choice over which hospital or physician treats you. Before the No Surprises Act, if the nearest emergency department was out‑of‑network, you could face balance billing—even if you went there in good faith.

• In‑Network Facilities, Out‑of‑Network Providers: You may choose an in‑network hospital, but the care you receive can be from out‑of‑network anesthesiologists, radiologists, or hospitalists working there. Those providers could bill you for the balance unless protected.

• Air Ambulance Services: Transportation by out‑of‑network air ambulance companies, even from an in‑network hospital, has been a major source of surprise bills.

The No Surprises Act (Effective January 1, 2022)

The No Surprises Act is a federal law that protects you from unexpected out-of-network bills in the following areas:

1. Emergency Services
   You cannot be balance‑billed for emergency care, regardless of where you are treated or whether the provider is in‑network Centers for Medicare & Medicaid Services.

2. Non‑Emergency Services at In‑Network Facilities
   Out‑of‑network providers at in‑network hospitals or ambulatory surgical centers cannot balance‑bill you unless you’ve given informed, advance consent and a written estimate at least 72 hours before non‑emergency care NCSL American Medical Association.

3. Good Faith Estimates
   Uninsured or self‑pay patients are entitled to a good faith estimate of expected charges before care, helping them avoid surprises entirely American Medical Association.

4. Independent Dispute Resolution
   When insurers and providers cannot agree on payment, an independent arbitrator determines a fair amount, ensuring patients pay only in‑network cost‑sharing Centers for Medicare & Medicaid Services.

Key Indicators to Identify a Surprise Bill

• Out‑of‑Network Provider Charges

  • Check whether any provider listed on your bill is out‑of‑network, even if the facility is in‑network.

• Balance Billing Line Items

  • Look for a line item labeled “balance bill” or “patient responsibility”—a sign that the provider billed you for the remainder of their charge beyond the insurer’s payment.

• Discrepancies Between Bill and Explanation of Benefits

  • Compare each service and charge on your bill with your insurer’s EOB; any services billed but not shown on the EOB raise a red flag.

• Unrecognized Providers or Charges

  • Watch for charges from specialists you didn’t request or unfamiliar provider names—common culprits include emergency physicians and radiologists.

• Missing Good Faith Estimate

  • If you’re uninsured or paying cash, you’re entitled to a Good Faith Estimate; its absence before scheduled care suggests you may face surprise charges.

• Air Ambulance and Ancillary Services

  • Services like air ambulances frequently operate out‑of‑network, even from in‑network facilities, which can trigger hefty surprise bills.

Steps to Verify Your Bill

1. Obtain an Itemized Bill

• Request a detailed, itemized bill from the provider’s billing office to see every procedure, test, and charge.

2. Review Your Explanation of Benefits (EOB)

• Match each itemized charge to your insurer’s EOB; flag any services on the bill that don’t appear on the EOB or show unexpected cost‑sharing.

3. Check Network Status

• Use your insurer’s provider directory or call customer service to confirm whether each provider is in‑network.

4. Look for Advance Notices and Consent Forms

• For scheduled, non‑emergency care, ensure you received a written estimate and gave consent at least 72 hours beforehand—required under the No Surprises Act.

5. Contact Your Insurer and Provider

• If you spot out‑of‑network charges or billing errors, immediately call your insurer and the billing department to request corrections or a network rate application.

6. File a Dispute or Complaint

• When protections are violated, file a formal dispute through your insurer and, if needed, submit a complaint to the Centers for Medicare & Medicaid Services (CMS) via CMS.gov/nosurprises or call 1‑800‑985‑3059.

At Patient Protection Project, we help people understand their medical bills, fight unfair charges, and get the care they need without being crushed by the cost. If you think you’ve received a surprise bill or need help understanding what you owe, reach out.